Bench- Sheko zone is found in Southwest Region which is the new formed region of Ethiopia. Its administrative center is Mizan-Aman Town which is located 562 km far from the capital city of Addis Ababa, Ethiopia. The total population of the zone for the year 2017 is estimated to be 613,146, of whom 303,321 were male and 309,825 were females . The zone has 6 districts and one town administration. It has 26 public health centers and 1 teaching hospital. The hospital had 540 antenatal care (ANC) attendants which estimated based on the 3- month average ANC follow-up women before data collection started in 2021. Kaffa zone is one of the 5 zones in Southwest Region which is located in southwest Ethiopia. Administratively, the zone has 10 districts and one town administration. Its administrative center is Bonga town which is far 468 km from the capital city Addis Ababa. The total population of the zone for the year 2017 is estimated to be 1,102,278, of whom 541,682(49.14%) are male and 560,596(50.86%) were female . The kaffa zone has one general hospital, one primary hospital, and 43 public health centers. Based on a 3-month estimated average ANC follow –up of women before a data collection, there have been 490 and 401 ANC attendants in the general hospital and primary hospital respectively, by 2021.
Study design and period
An institutional-based cross-sectional study design was conducted from May 20-June 30 in 2021.
All pregnant women who attended ANC at the public hospitals in Bench-Sheko and Keffa zones.
Systematically selected study participants from those who came to the public hospitals for ANC follow-up during a study period.
Is the pregnant women from whom information was collected.
Inclusion and exclusion criteria
The study subjects were all pregnant mothers who were attending public hospitals for ANC and who lived for at least 6 months in the study area.
Mothers too sick or mentally not stable to respond to questions.
Sample size and sampling technique
Sample size determination
In this study, the single population proportion formula was used to figure out the sample size. The prevalence of good dietary practices is thought to be 33.9% , 5% margin of error, 95% confidence level, design effect of 1.5, and a none response rate of 10%. Based on this, the actual sample size was: n = (zα/2)2 p (1-p)/d2 = (1.96)2*0.339(1–0.339)/0.052, n = 344. Then, the design effect of 1.5 was considered (344*1.5) and became 516. A 10% none response rate was considered, then the minimum sample size required became: 516 + (516*10%) = 568. Hence, the final sample size of this study became 568.
Sampling technique and procedure
First, the total sample sizes were proportionally allocated to each public hospital of the Bench-Sheko and Kaffa zone (Mizan-Tepi University Teaching hospital, Gebretsadek-Shawo General hospital and Wacha primary hospital), that were all hospitals included in the study. The total population size of each public hospital was estimated by using the average number of clients attending ANC for the last 3-months based on their registration card, before the data collection period. Then, the sampling interval (Kth) was calculated by using the formula of K = N/n. Next, prospectively every Kth (roughly 2) person was selected by using a systematic random sampling technique until the desired sample size was attained from each hospital.
The dependent variable in this study was maternal dietary practices during pregnancy, whereas the independent variables were age, marital status, religion, family size, occupation, education, income level, radio, trimester, number of pregnancy, number of live birth, pregnancy interval, number of ANC visit, food security status, residency, dietary information, dietary knowledge, dietary attitude, and history of illness.
Data collection procedures
Structured and semi-structured questionnaires were administered by trained health professionals (Nurses and Midwifes) to collect the data. Data on socioeconomic status, pregnancy-related factors, and household food insecurity status were collected. The pregnant women's knowledge and attitudes about food were also assessed.
Pregnant women's dietary practices were assessed using a questionnaire adapted from previous literature [6, 17] and FAO Guideline . Pregnant women's dietary practices were assessed retrospectively using a measurement of method of short food intake checklist that asked whether a particular list of food was consumed the previous 24 h with the answer being Yes or No; nutrition-behaviors checklists measurements, which are used to assess specific observable behaviors or practices that are some important practices for nutrition during pregnancy but cannot be assessed through food intake measurements  and meal frequency. Ten items were used to assess pregnant women's dietary practices. The dietary practices score was calculated by adding the responses to each question. Each question received one point if the response was correct, favorable, or healthy for dietary practices, and zero points if the response was incorrect, unfavorable, or unhealthy for dietary practices during pregnancy [6, 15, 28, 30]. Finally, participants were classified as having poor dietary practices and as having good dietary practices [6, 31, 32].
Ten open-ended questions adapted from a previous study were used to assess dietary knowledge [16, 17], which sought to assess pregnant women's knowledge of nutrition-related topics and recommended dietary advice during pregnancy . Its reliability was evaluated in this study and revealed a Cron-bach Alpha of 0.92. The items assessing nutritional knowledge were scored on a dichotomous scale, with 0 indicating ignorance and 1 indicating knowledge. A correct response was coded as 1 and an incorrect response as 0. Then, the total score was obtained by summation of each score. Finally, nutritional knowledge level was categorized as knowledgeable and not knowledgeable [16, 28].
Pregnant women's attitudes toward their dietary practices during pregnancy were assessed using questioners adapted from previous studies and conceptualized for the local context [16, 17]. Maternal dietary attitudes were elicited through the use of nine questions in this study. Respondents were asked to rate their favorableness or unfavorability toward a particular dietary regimen during pregnancy. The reliability of the attitude questions was checked and showed a Cronbach Alpha of 0.84. The pregnant women were given one mark if the answers were favorable attitude for dietary practices and while zero scores were given if the responses were unfavorable [16, 31]. After the summation of the score, the respondent was categorized as favorable attitude and unfavorable attitude 
The Household Food Insecurity Access Scale (HFIAS) was used to measure the level of food insecurity in each household. This is a structured, standardized, and validated tool that was mostly made by FANTA [34, 35] and a scale is a valid tool in measuring household food insecurity among both rural and urban areas of Ethiopia . Food insecurity (access) is measured using nine questions that represent increasing levels of severity and nine "frequency-of occurrence" questions that ask about the changes in diet or food consumption patterns that households have made due to limited resources in the previous 30 days. Participants received a score ranging from 0 to 27 based on their answers to nine questions and the frequency with which they occurred over the previous 30 days. A lower HFIAS score indicates better access to food and less household food insecurity, whereas a high HFIAS score indicates a lack of access to food and a lack of food insecurity .
Data quality assurance
In order to ensure the validity of the data, a pre-test was conducted among 5% of the study participants. Amharic and English translations of the final questionnaire were done in order to better understand the respondents' native language. All data collectors received two days of in-depth training on the instruments and methods for data collection, as well as the ethical issues involved in conducting a research project. Throughout the data collection period, supervisors checked the collected data for completeness, accuracy, and consistency, and the principal investigator was in charge of overall supervision. A comparison of two data cells was made using double data entry.
Data analysis methods
After verifying that all data were complete and consistent internally, they were coded and entered into the Epi Data 3.1 version computer software package, which was then exported to the Statistical package for social science (SPSS) version 21 software for further analysis. Percentage, frequency, mean, and standard deviation were calculated for the descriptive statistical analyses. We used bivariable logistic regression to examine the relationship between the dependent and independent variables. The variables with a P-value < 0.25 during bivariable logistic regression analysis were considered for multivariable logistic regression models to control all possible confounders and to identify factors independently associated with the dietary practice of pregnant women. The Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with 95 percent confidence intervals (CI) were calculated to determine the strength and direction of association between dependent and independent variables. Finally, the variable with (p-value < 0.05) in multivariable logistic regression analysis was considered statistically significant. Multicollinearity between independent variables was checked by using standard error (SE) and variables of SE > 2 were dropped from the analysis. The model fitness was tested by Hosmer- Lemeshow for the goodness of fit and model fitted was considered at Hosmer–Lemeshow P-value > 0.05.
This is the observable action of the mother that could affect her nutrition such as eating, feeding, cooking, and selecting foods. The study participants were classified as having poor dietary practices if they correctly answered < 75% of dietary practice questions and good dietary practices were if they correctly answer ≥ 75% of questions [31, 32].
Is awareness and understanding that one has gained on nutrition during pregnancy through learning and practice. The pregnant women were considered to be knowledgeable if they were correctly answered ≥ 70% of the total knowledge assessing questions and non-knowledgeable if respondents score < 70% on the knowledge questions [16, 33].
Pregnant women’s feeding or eating behavior is influenced by their emotions, motivations, perceptions, and thoughts. In this study, the favorable attitude was if the respondent's attitude score > the median and while unfavorable if the respondents ‘attitude scores were ≤ the median .
Households those experiences none of the food insecurity (access) conditions or just experience worry, but rarely in the past 4 weeks were labeled as ‘food secured or food secure households who were experienced fewer than the first 2 food insecurity indicators.
The inability of households to access sufficient food at all times to lead an active and healthy life (includes all stages of food insecurity; mild, moderate, and severe) . A household that was an experience from 2–10, 11–17, and > 17 food insecurity indicators were considered as mildly, moderately, and severely food insecure households, respectively.